Failure to Offer and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer influenza and pneumococcal vaccinations to one resident upon admission, as required by both facility policy and CDC recommendations. The resident in question had diagnoses including dementia and schizoaffective disorder and was under the legal care of a public conservator. Review of the clinical record revealed no documentation that the resident or their responsible party had been offered the vaccines, nor that the risks and benefits had been explained verbally or in writing. The Infection Control Nurse (ICN) acknowledged that she had asked the Social Services Director to assist in contacting the conservator for consent but did not follow up, resulting in no action being taken. Interviews with the ICN and the Director of Nursing confirmed that all residents should be offered these vaccines, with proper documentation of acceptance or refusal and education on risks and benefits. The facility's own policies require annual influenza vaccination offers and pneumococcal vaccination offers for eligible adults, with informed consent or refusal documented in the medical record. In this case, the process was not completed, and there was no evidence of an offer or consent for the resident, constituting a failure to follow established procedures.